Fertility 3

Question 1

How is tubal damage detected?

Answer 1

• Laparoscopy and dye test- allows visualisation and assessment of fallopian tube patency, methylene blue is injected through the cervix from the outside and seen to spill out of the tubes (patent) or not (non-patent)
• Hysteroscopy- performed to first assess the uterine cavity for abnormalities
• Hysterosalpingogram (HSG)

Question 2

What is a hysterosalpingogram (HSG)?

Answer 2

radio-opaque contrast is injected through the cervix
spillage from fimbrial ends can be seen on x-ray
a variant of this test can be used with transvaginal USS and ultrasound opaque liquid
less invasive than laparoscopy, but endometriosis and periovarian adhesions may not be diagnosed unless they cause tubal damage

Question 3

What are the types of assisted conception?

Answer 3

o IUI
o IVF ± ICSI
o Frozen embryo replacement (FER)
o Oocyte donation
o Preimplantation genetic diagnosis (PGD)
o Preimplantation genetic screening (PGS)
• Success is best measured with the live birth rate- declines after 35yrs and even more >40yrs- sperm quality is also important but ICSI makes this less important

Question 4

What is intrauterine insemination (IUI)?

Answer 4

• Washed sperm are injected directly into the cavity of the uterus-can be performed during a natural menstrual cycle
using urinary LH testing for ovulation so insemination can be following gonadotrophin ovulation induction
• Suitable for couples with unexplained subfertility, cervical, sexual or male factor problems
• Tubes should be patent as the oocyte still needs to travel from the ovary to the sperm, so cycles should be regular and ovulatory for natural cycle IUI
• For stimulated IUI- the live birth rate is 5-10% per cycle with a 15% risk of multiple pregnancy

Question 5

What are the live birth rates for IVF?

Answer 5

o <36yrs- 35% per stimulated cycle

o 40yrs- <10% per stimulated cycle

Question 6

How is ovarian reserve measured for IVF?

Answer 6

• Normal ‘ovarian reserve’ is needed so that sufficient oocytes will be collected for fertilisation and transfer
best assessed using serum levels of AMH, as it is produced in the ovary so a direct measure, an alternative measure is transvaginal USS to count the number of resting small follicles in the ovaries (AFC)

Question 7

What are the stages of IVF?

Answer 7

o Multiple follicular development
o Ovulation and egg collection
o Fertilisation and culture
o Embryo transfer

Question 8

What is multiple follicular development?

Answer 8

achieved using 2 weeks of daily subcutaneous gonadotrophin injections (FSH±LH)
an additional drug must be used to prevent endogenous LH surge and premature ovulation before oocyte collection

Question 9

What is long protocol IVF?

Answer 9

daily GnRH is started on day 21 and continued for 2-3 weeks to suppress pituitary FSH & LH production
leading to ovarian quiescence
once suppression is confirmed by a low oestrogen level or thin endometrium then gonadotrophin stimulation begins
GnRH analogue is continues along with gonadotrophin stimulation until just before egg collection

Question 10

What is short protocol IVF?

Answer 10

pituitary suppression is not achieved before starting gonadotrophin stimulation
instead a daily GnRH antagonist is added from around day 5 of gonadotrophin stimulation, continued until just before egg collection

Question 11

What occurs with ovulation and egg collection in IVF?

Answer 11

once an optimal number of mature size (15-20mm) ovarian follicles are confirmed with scan monitoring the drugs are stopped
a single injection of hCG or LH is then given to trigger final oocyte maturation
35-38hrs later the eggs are collected under intravenous sedation by aspirating follicles transvaginally under USS guidance

Question 12

What occurs with fertilisation and culture in IVF?

Answer 12

eggs are incubated with washed sperm and transferred to a growth medium
embryos are cultured until cleavage (day 2-3) or blastocyst (day 5-6) stage ready for transcervical uterine transfer
spare, good-quality embryos can be frozen for future thawing and FER during a natural or HRT treatment cycle

Question 13

What occurs with embryo transfer in IVF?

Answer 13

two cleavage embryos are transferred with a 25% twin pregnancy rate
blastocysts have a higher implantation potential, so eSET may produce similar pregnancy rates but are more prone to late division causing monochorionic twin pregnancies
luteal phase support using progesterone or hCG is given until 4-8 weeks gestation

Question 14

What is intracytoplasmic sperm injection (ICSI)?

Answer 14

• Injection of one sperm with a very fine needle into the oocyte cytoplasm
it is a laboratory adjunct to IVF
• Useful in male factor infertility when there is not enough motile sperm for standard IVF
• Sperm can be retrieved from the testes, frozen and then thawed during a fresh IVF cycle and used for ICSI

Question 15

What is oocyte donation?

Answer 15

• Some women cannot conceive with their own eggs- due to ovarian failure, older age or genetic disease
• Oocyte donors go through a full stimulated IVF cycle- retrieved oocytes are fertilised with the sperm of the
recipient woman’s partner
• Recipient women receives oestrogen and progesterone to prepare her endometrium for transfer of the fresh embryo

Question 16

What is preimplantation genetic diagnosis?

Answer 16

• Blastocytes contain >100 cells- in PGD 3-5 cells are removed from the trophoectoderm (pre-placenta) and the DNA is examined using techniques of karyomapping or PCR to look for genetic abnormalities
• Unaffected embryos are then thawed and replaced in the uterus for a subsequent menstrual cycle with or without exogenous hormone therapy
• PGD is used for couples who are carriers of single-gene defects (CF) or who have chromosome translocations placing them at high risk of conceiving a child with aneuploidy
• Women can have their IVF blastocysts biopsied, frozen and ‘screened’ using PGS to identify chromosomally ‘normal’ embryos for later transfer in an attempt to overcome the age-related decline in IVF live births

Question 17

What are the complications of assisted conception

Answer 17

• Superovulation- multiple pregnancy and ovarian hyperstimulation
• Egg collection- intraperitoneal haemorrhage and pelvic infection may complicate USS-guided aspiration of mature follicles necessary for IVF, risk is low (1%)
• Pregnancy complications- rate of ectopic pregnancy can be higher

Question 18

What are the types of fertility preservation?

Answer 18

• Men or adolescent boys whose fertility is at risk can freeze sperm samples- this can be thawed at a later date and used during an IVF cycle to inseminate the partner’s eggs
• Women need to undergo an IVF cycle to have her eggs or embryos collected and frozen for later use, for embryos both parents must give consent for it to be thawed
Live births following single IVF cycle and egg or embryo freezing is 30-50% for women <37yrs
• Cryopreservation of ovarian/testicular tissue, grafted back after treatment